MEDICARE: LICELYA MENDEZ-PINEDA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician
2	106S00000X	Behavior Technician	RBT-18-60332	CA

General Provider Information

NPI Number	:	1750867925
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LICELYA MENDEZ-PINEDA

Provider Business Mailing Address
First Line	:	2770 W DEVONSHIRE AVE APT K10
Second Line	:
City	:	HEMET
State	:	CA
Zip	:	92545-5059
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25190 HANCOCK AVE STE C
Second Line	:
City	:	MURRIETA
State	:	CA
Zip	:	92562-5984
Country	:	US
Telephone Number	:	951-200-5532
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2018
Last Update Date	:	09/24/2020

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